Welcome to the investigative reporting blog of award-winning journalist Alex Roslin, author of the book Police Wife: The Secret Epidemic of Police Domestic Violence. Roslin was president of the board of the Canadian Centre for Investigative Reporting, and his awards include the Arlene Book Award of the American Society of Journalists and Authors, for the book Police Wife. Below are samples of his work.

Critics say doctors should be forced to disclose goodies they receive from drug company reps

Alex Roslin

Saturday, September 12, 2009

The Montreal Gazette

Adam Hofmann is used to getting teased about his lunch.
It’s not because his mom gave him something uncool to eat. It’s because he paid
for it.

Hofmann is a doctor and fifth-year medical resident atMcGillUniversity.
Lunchtime is often when residents attend talks on medical topics organized by
various disciplines in the three teaching hospitals where Hofmann works—the
Montreal General,RoyalVictoriaHospital and the
Jewish General.

Sales reps from pharmaceutical and medical-equipment
companies provide the food and sponsor the speaker at many of the talks, he
said.

The sessions, known as “rounds” among doctors, occur two to
four times a month within any given hospital discipline like cardiology or
internal medicine, Hofmann said.

Drug reps also frequently provide food and sponsor speakers
at monthly “grand rounds”—talks to entire hospital departments like pediatrics
or family medicine—and “journal clubs,” meetings at restaurants or doctors’
homes at which medical papers are discussed, he said.

While his coworkers partake in sushi takeout or a catered
spread, Hofmann sticks to cafeteria fare and braces for the funny looks. He is
virtually always the only attendee to pay for his meal. “I have occasionally
gotten sarcastic remarks. I’ve been called a ‘pinko’ and a ‘communist’,” he
said with a laugh.

With 10 to 20 rounds taking place each day in an academic
hospital, Hofmann said staff are able to eat lunch for free all week if they
want to, and some do. “A few residents have made it a game to never pay for
lunch if at all possible, even going to the length of seeking out lectures they
would not otherwise be interested in,” he said.

He estimated that the average resident in academic
hospitals eats for free two or three times a week.

For Hofmann, brown-bagging it is a small price to pay to
avoid the cozy interactions that many medical professionals have with
pharmaceutical sales reps.

Questions about drug marketing practices are coming under
growing scrutiny inCanada and
theU.S. In
August, McGill professor Barbara Sherwin was embroiled in questions about a
journal article that was ghostwritten for her by a company working on behalf of
a pharmaceutical firm.

Last week, the drug giantPfizer Inc.
agreed to pay $2.3 billionU.S.to
settle criminal and civil allegations that it had illegally marketed several
drugs for unapproved uses and rewarded doctors with kickbacks. It was the
largest criminal fine in history and was Pfizer’s fourth settlement for illegal
marketing in theU.S. since
2002.

Little data exists on the extent of the marketing
activities in Quebec.One of the few
Canadian studiesfound,
in 2006, that 42 per cent of general practitioners in B.C. got visits from drug
sales reps several times a week. Two-thirds saw them at least once a month.

The visits are part of vast, multi-billion-dollar marketing
campaigns that include food brought to doctors’ offices, restaurant meals,
trips, high-paying gigs as consultants and speakers, drug samples, research
grants and continuing-education talks that doctorsattend to maintain their
licences.

Critics say the marketing is poorly regulated and that a
growing pile of studies shows the perks sway doctors to prescribe costlier
drugs that aren’t necessarily the best ones for their patients—a major reason
for soaring health-care costs.

“The gross majority of interactions that physicians have
with pharmaceutical companies are unnecessary and problematic,” said Hofmann.

***

Pushing pills involves fantastic amounts of money. Ina
study in 2008in the
journal Public Library of Science Medicine, two Canadian academics, Joel
Lexchin and Marc-André Gagnon, calculated that pharmaceutical companies spent
$57.5 billion on marketing in the U.S. in 2004. That was nearly double the $32
billion spent on researching and developing drugs.

The marketing budget included $20.4 billion for an army of
100,000 “detailers,” as the sales reps are known in the business. That worked
out to about one detailer for every nine doctors; their numbers had swelled by
nearly three times since 1995.

All those detailers and marketing bucks have big impacts on
medical decisions of doctors, according to one of the most comprehensive
scientific reviews of the question, done by Dr. Ashley Wazana, now a
psychiatrist at the Jewish General.

Those who “occasionally” ate pharma-sponsored meals were
2.7 times more likely to request that the sponsor’s drug be added to a hospital
formulary (a hospital-approved list of drugs). Doctors who “often” ate the
meals were 14 times more likely to do so.

Thereview
also noted that hearing a drug salesman at a talk led doctors to recommend
“inappropriate treatment” more often than other doctors, including treatment
that cost more and was more invasive.

Wazana also found that just one in five doctors agreed that
pharma reps “fairly portray their product.” Three-quarters of residents said
the reps “may use unethical practice.”

Despite this, most doctors have some interaction with
detailers. Four in five residents attended industry-paid meals, with the
average resident eating on the corporate dime 14 to 15 times a year, Wazana
found. Interns did so 31 times a year.

Among doctors, 85 to 87 per cent said they had some
interaction with detailers, with an average of three to four encounters a
month. Eighty-six per cent accepted free drug samples, and half got research
grants.

The interactions start right in med school. Asurvey of 826U.S.medical studentspublished in 2005 found that 97 per
cent had received some form of gift from pharma reps. Students got gifts or
attended a sponsored activity an average of once a week, and they ranged from
lunch to parties, trips and candy. More than two-thirds said the gifts would
never influence their prescribing practices.

In fact, many doctors rely on detailers more than any other
source for information about new drugs.U.K. doctors
said drug reps were their most important source of initial information in a
third of the cases when they prescribed new medicines, with pharmaceutical
marketing accounting for another 15 per cent, according to a2003
studyin thejournal Family Practice.

That study also reviewed 616 prescriptions the doctors had
written. The doctors cited pharma reps more often than any other factor as
influencing their prescription choice. The reps were cited 39 per cent of the
time, far more than concern about the drug’s side effects (17 per cent) or
prescribing guidelines developed by the medical community (15 per cent).

The marketing has paid off in spades for the pharmaceutical
industry, according to a2002 studyby Yale University marketing professor
Dick Wittink. He found that each dollar spent lobbying doctors through sales
reps and pharma-sponsored events returned nearly $12 in increased prescriptions
for brand-name drugs.

At the Quebec Medical Association, which represents 9,000
doctors and medical students, an official said the research is news to him. “We
are not aware of that. We haven’t studied this question,” said Robert Nadon,
the association’s director of professional affairs.

“We think doctors are professionals and that they will
respect their ethics code.”

Russell Williams, president of Rx&D, the Canadian
lobby group for brand-name drug companies, said member companies followan ethics code,
which says product information given to medical professional must be “accurate
and fair” and that gifts to doctors can’t be “excessive” and must be limited to
“modest meals and/or refreshments.”

The code adds, “Hospitality should not be utilized as the
primary access to meet with health care professionals, but as an opportunity to
expand the business discussions.”

“I believe our industry is dealing with this issue in an
upfront way,” said Williams. “We’re not selling shoes here. These are complex
molecules. We need to have dialogue with doctors.

“There is a significant engagement from our side to make
sure that the relationship is of the highest ethical standards. It is working
quite well.”

Officials at the McGill University Health Centre, the
Jewish General and the Centre hospitalier de l’Université de Montréal couldn’t
be reached for comment.

The body that representsQuebec hospitals and
CLSCs has no policy on staff interactions with pharma reps, said Eric Côté,
spokesman for the Association québécoise d’établissements de santé et de
services sociaux. “Technically, doctors are autonomous workers.”

Côté referred calls to the Quebec College of Physicians.
The college said it expects doctors to abide byits
ethics code, which says continuing education classes must be “balanced”
and that doctors should avoid conflicts of interest. Doctors can’t accept
commissions or benefits for having prescribed a drug, but they can accept
“customary presents and gifts of modest value.”

But critics say the rules are nebulous. “It’s so vague as
to be completely useless,” Hofmann said.

“Also, there are generally minimal and infrequent
repercussions associated with these kinds of ethics code violations.”

“Drug companies would not be detailing physicians if they
didn’t have a huge return on investment. They’re in the business of making
money,” said Jeff Connell, spokesman for the Canadian Generic Pharmaceutical
Association.

Connell said his association’s members lose business and
patients pay more when detailers steer doctors to more expensivebrand-name drugs that aren’t
necessarily more effective than similar generic versions. When a drug’s patent
is about to expire, he said, brand-name pharmaceutical companies often make
minor changes so they can patent the medicine anew and then get doctors onside
with aggressive marketing campaigns.

Indeed, of 177 new drugs approved in Canada since 2001,
federal regulators deemed that 156 (or 88 per cent) fell in a category of drugs
that show “moderate, little or no therapeutic advantage over comparable
medicines.” Just 19 of the drugs were considered “a breakthrough or substantial
improvement,” according todata from the
federal Patented Medicine Prices Review Board.

When Shahram Ahari was hired as a detailer inNew York City by a majorU.S. pharmaceutical
firm, he was surprised when he met his co-workers. At the company’s intensive,
six-week boot camp for detailers, he said he met hundreds of fellow college
grads, mostly in their mid-20s, perhaps two-thirds of them women—the vast
majority beautiful. He was the only one in his class of 22 with a science
degree.

“They were 200 or 300 of the most attractive people I had
ever seen. The physical appeal was only part of it. They were vivacious,
well-coiffured, well-dressed, engaging people,” he said.

The training was partCIA,
part Freud. Ahari learned to quickly scan a doctor’s office and spot anything
that could be used to strike up a personal conversation and, with luck, friendship—golf
paraphernalia, photos of trips or kids, religious items. The information would
later be entered into the company’s file on the doctor and analyzed for future
approaches.

“It was analogous to training in spy agencies. You
instantly suss up the person’s personality and look for points of entry. You
capitalize on sexual appeal. My more attractive colleagues would say, ‘I’m
going to wear my short skirt today,’ or ‘I’m going to wear my low-cleavage top.
He (the doctor) seems to get a kick out of that,’” he said.

His in with many doctors was their belly. “Food is a pretty
powerful catalyst for sales. I sometimes saw myself as a glorified caterer,” he
said.

Food would often have a greater impact than his best
arguments about a drug’s merits. “I would argue with doctors until I was blue
in the face (about a drug). Then I’d take them out to dinner and see their
(prescription) numbers rise,” he said.

Ahari often provided food at hospital “rounds,” and he was
also careful not to neglect the staff at doctors’ offices; they could be useful
for scheduling appointments with doctors and putting in a good word about his
company’s drugs.

“There’s almost a sub-art to figuring out which food people
will like. How successful and delicious your lunch is has a sway in terms of
how quickly you can get meetings (with the doctor),” he said.

He rewarded high prescribers with an invitation to join the
company’s “speaker’s bureau.” That meant lucrative gigs addressing other
doctors at company-sponsored lunch and dinner meetings and medical symposiums.
Speakers typically earned $100 to $500 for a lunch or dinner presentation and
up to $10,000 for a major conference talk.

“We’re constantly monitoring our return on investment.
We’re not a charity,” Ahari said. “There’s no such thing as a free lunch. It’s
the patient who pays.”

***

The revelations about drug marketing practices have pushed
a few U.S. states to ban gifts to doctors, limit their value or require them to
be disclosed publicly.

InCanada,
there has been less scrutiny and less action. Some provinces, including Ontario
and B.C., have sent out small numbers of so-called “academic detailers” in an
effort to counter the pharma message and provide independent drug information
to doctors.

But critics say a handful of academic detailers can’t
possibly counter the huge numbers of pharma reps and that doctors have shown
they can’t police themselves.

Ahari and Hofmann both said doctors should be forced to
publicly disclose any benefits they receive. Another measure, said Hofmann, would
be for revenue authorities to require doctors to include free drug samples and
meals as income and to tax it.

Ahari said he eventually quit his job as a detailer because
of his rising ethical concerns. “Not only are you fooling your (doctor)
clients, you’re fooling yourself that you’re doing something good,” he said. “I
felt I had become such a calculating social manipulator I would be thinking
like a chess game in every social encounter with my girlfriend and family. It
was horribly disconcerting.”

Ahari has since spoken before Congress, at medical schools
and to the American Medical Association about detailing and conflict of
interest. He is now attending medical school himself at the University of
California at Davis.

Back at McGill, Hofmann hopes his cafeteria lunches will
get a colleague or two to question the price of the food they’re enjoying.

“It’s an obvious stance that physicians should take.
Getting gifts from an industry that seeks to manipulate your prescribing
practices and may adversely affect your patients is unethical.”

As hospitals
brace for the coming flu season and a possible new surge of H1N1 cases,
international data on the flu pandemic shows it has hit Canada worse than
almost any other country.

And a close
look at the data suggests that a key factor may be something that health
authorities have largely overlooked: hog farming.

Canada had
the sixth-highest number of H1N1 cases per capita and the fifth-highest per
capita rate of H1N1 deaths of all 134 countries and dependencies that had
reported flu cases to the World Health Organization as of July 6. (That’s the
last date for reliable international comparisons, because the WHO advised
countries in early July to stop reporting data on individual H1N1 cases.)

Canada’s
H1N1 rate was almost 15 times the global average—23.7 lab-confirmed cases per
100,000 people, compared to an international average of 1.6 cases per 100,000,
according tothe WHO data. Canada’s
per capita rate was double that of the U.S. and 2.5 times that of Mexico, where
the pandemic is thought to have started.

Canada’s
H1N1 death rate was 10 times the international average: 7.4 deaths per 10
million people, versus 0.7 globally.

It’s not
clear why Canadian H1N1 rates are so high. One possibility is that Canadian
medical authorities have simply sent more cases to labs for testing. But the
data also suggests another possible factor: Canada’s high concentration of hog
farms.

It just so
happens that Canada has the world’s eighth-highest number of pigs per
capita—almost 15 million pigs, or about one for every two Canadians. And an
analysis of international flu data shows that H1N1 rates have strong
correlations with hog farming.

In Mexico,
where it probably all started, there was a moderate, statistically significant
46-percent correlation between confirmed per capita H1N1 cases in all of the
country’s 32 states and its federal district and the number of pigs per capita
in those states. That’s according tothe
data as of July 2, the date the Pan American Health
Organization stopped publishing the breakdown of flu cases within countries of
the Americas.

(Correlation
measures the strength of the relationship between two groups of data. A
correlation of 30 to 50 percent is generally considered to be moderate, 50 to
70 percent is strong, while 70 percent or higher is very strong.)

Yucatán was
the Mexican state with the highest rate of H1N1 cases per capita: 92 per
100,000 people. It’s also one of the country’s hog-farming hubs, with the most
pigs per capita of any state, more than one for every two people.

Argentina
had the world’s highest per capita death rate from H1N1, with 15 deaths per 10
million people, or 20 times the world average of 0.7 deaths. In Argentina’s 24
provinces and its capital district, there was a 70-percent correlation between
the per capita death rate and the ratio of pigs to people.

The
Argentinean province that had the highest death rate was Santa Fe, with 130
H1N1 deaths per 10 million people. Santa Fe also happens to have Argentina’s
highest ratio of pigs to people.

And those
countries aren’t the only ones where there’s apparently a relationship between
the pandemic and hog farming. Among the 39 countries and dependencies in the
Americas that had reported H1N1 cases as of July 6, there was a 51-percent
correlation between H1N1 cases per capita and the number of pigs per capita.

Globally,
the 20 countries with the most pigs per capita had a per-capita H1N1 rate of
5.5 per 100,000—more than 3.3 times the international average of 1.6 cases. As
well, their per capita death rate from H1N1 was 2.5 per 10 million, or more
than triple the international average of 0.7.

“This is a
very serious concern,” said Bob Martin, who headed the Washington, D.C.–basedPew
Commission on Industrial Farm Animal Production, when told
about theGeorgia Straight’s data
analysis. “It’s just another step in showing what serious impacts these
large-scale swine operations can have.”

Martin’s
commission releaseda studylast year that said workers in large farms, and
their neighbours, have high rates of asthma and other respiratory illnesses due
to manure runoff and emissions like ammonia and fine-particle pollution.
Respiratory illness makes people more vulnerable to H1N1, he said.

A high
portion of H1N1 hospitalizations and deaths have occurred among people with an
additional medical condition like asthma or a compromised immune system.

In aninitial story in July, theStraightreported that strong correlations
exist between per capita H1N1 rates and the number of pigs per person within
B.C.’s five health regions and in each of Canada’s provinces.

As of July
8, Manitoba, the country’s hog-farming capital, with 2.4 pigs per person, had
three times as many H1N1 hospitalizations per capita as the Canadian average
and 3.7 times as many deaths per capita.

The
international data puts the high Manitoba numbers into even starker
perspective. Manitoba’s per-capita H1N1 rate, 65 per 100,000 people, was 40
times higher the international average and far worse than that of the country
with the highest rate in the world, Chile, which had 44 cases per 100,000.

Manitoba’s
death rate—41 per 10 million people—was 60 times the global average and nearly
three times that of Argentina, the worst-hit country in the world in terms of
deaths.

So far,
Canadian public-health officials have said the flu pandemic is spreading mostly
randomly, though they acknowledge it has hit some vulnerable populations harder,
especially those with respiratory problems, aboriginal people, and pregnant
women. Most scientists believe H1N1 originated on a huge Mexican factory pig
farm, then spread between people around the world.

In Canadian
aboriginal communities, H1N1 is thought to be worse because of poor health care
and overcrowding. Indeed, the data confirms that Native people have been hit
harder and need extra resources to deal with H1N1. The per capita number of
H1N1 cases in each province had a very strong 87-percent correlation with the
per capita number of aboriginal people.

That’s even
higher than the 77-percent correlation between per capita H1N1 cases and the
per capita number of pigs in the 10 provinces.

However,
when it comes to more serious H1N1 cases that involved hospitalization and
death, the correlations were stronger for hog farming. There was a 44-percent
correlation between per capita H1N1 hospitalization rates and the number of
aboriginal people per capita in each province, compared to a 72-percent correlation
between hospitalization rates and the per capita number of pigs in each
province.

H1N1 deaths
per capita had an 82-percent correlation with the percentage of aboriginal
people in each province, but had an even stronger 89-percent correlation with
the number of pigs per capita.

“I hope the
World Health Organization will start looking at the same data you’re looking
at,” the Pew Commission’s Martin said in a phone interview.

Winner of the Arlene Book Award of the American Society of Journalists and Authors

Click the image to buy "Police Wife" on Amazon

About Alex Roslin

Alex Roslin is an award-winning journalist who was president of the board of the Canadian Centre for Investigative Reporting. He won the American Society of Journalists and Authors' Arlene Book Award for Writing that Makes a Difference for the first edition of the book "Police Wife: The Secret Epidemic of Domestic Violence," which he co-authored.

The book was also the runner-up for the Hollywood Book Festival non-fiction book award, won silver in the eLit Book Awards and bronze in the INDIEFAB Book of the Year Awards and was a finalist in the Next Generation Indie Book Awards. Roslin is the author of the updated and revised second edition of "Police Wife."

Roslin has also won three Canadian Association of Journalists prizes for investigative reporting and 10 nominations for CAJ awards and National Magazine Awards, including one for his story "Killer Cop" about RCMP Constable Jocelyn Hotte's murder of his ex-girlfriend Lucie Gélinas.

He has worked as an associate producer for the CBC-TV investigative programs the fifth estate and Disclosure and has written for The Montreal Gazette, The Financial Post, The Globe and Mail, The Toronto Star, Maclean's, L'Actualité, The Georgia Straight, Zoomer, Canadian Geographic, Today's Parent and many others.

He is chair of the nominations and awards committee of the Professional Writers Association of Canada.